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17 Partial vs. Total Knee Replacement

TRANSCRIPT

Welcome, friends, you’re in The Call Room with me, your host, Dr. Robert Berry. I’ll be giving you an insider’s look behind the scenes of all things related to health, fitness and the politics affecting health care. The Call Room is a place in a hospital normally only doctors are allowed to go. But I’m inviting you to be my guest as I take you behind the scenes. I’ll interview leaders in their fields and share my thoughts and perspectives as a orthopedic surgeon and health care leader.

So come join me inside The Call Room. Hey, guys, this is your host, Dr. Robert Berry, and I want to welcome you to another edition of In The Call Room. Today, we’re going to be talking about partial and total knee replacements. It’s one of the most common questions that I get asked. And many of you who have had knee pain or been told that you may need a knee replacement, probably asking this as well. And one of the things that people often want to know about is what’s the difference between a partial and a total knee replacement and what activities can you do or not do with a partial or with a total?

So we’re going to talk about that today. And there are lots of different ways to replace knees today and in future episodes we’re going to be talking about robotic replacement and how these new advances are helping us in the operating room, do total knees or partial knee replacements. But when we talk about a partial knee replacement, essentially what we’re talking about is just resurfacing or replacing just one part of the knee. And that could be the inside of the knee, the outside of the knee or underneath the knee cap or what we call the patella femoral joint.

And when we replace part of the knee, simply if you think of your knee, as I like to tell my patients, is the tires on a car, what you’re looking at is where it’s worn. Like if you notice on your car tires is wearing on the inside or on the outside, then there’s an alignment issue. And so although you can do partials or total replacements, this is not necessarily going to allow your knee to do all the things that you were able to do before you had a replacement.

That’s one of the things that patients need to understand. You can still live a very active lifestyle and do most of the things that you want to do. But this is what leads to my general recommendations with my patients about partials versus Total is that there’s really no difference in activity restriction between a partial and a total replacement. So as we begin the discussion, let me just set that framework that if you have a partial or if you have a total, there are some things that you’re still not going to be able to do that you may have been able to do with a natural knee with your knee that you were born with.

So let’s go into the partial. So why would one want to do a partial replacement? Well, that’s a good question. I think a lot of it is just because patients feel that they’re either oh I’m too young to have a partial replacement and I still want to be very active. And so they opt against having a partial or I should say a total replacement as a result of the activities they want to do. And it’s the same sort of explanation that we have in general with any type of joint replacement that people feel, oh, I’m too old, I’m too young.

And really there’s not a too old or a too young for having a joint replacement in general. What we will tell patients is when you feel like you’ve exhausted all conservative measures, whether that’s physical therapy, whether that’s injections now with regenerative medicine and platelet rich plasma stem cell injections, which we’ll talk about in another episode and how these may be other alternatives to joint replacement, then one may want to consider a joint replacement. So there’s not too old or too young and there’s not a one size fits all.

Everybody is different. And your surgeon, your doctor should come up with a plan that’s best for you. I’ve done joint replacement on people in their late teens, those would be rheumatoid patients that have juvenile rheumatoid arthritis that requires joint replacement. So and as old as ninety-nine I had many years ago, a patient who we did a knee replacement on that was ninety-nine, still very active and very healthy. So there’s not a too young or too old.

And one of the things that I think is important as we talk about joint replacement is most patients usually wait too long. They’ve suffered, they’ve gone through a lot of conservative measures, injections, and their knee just still hurts. And they can’t enjoy playing with their grandkids, going on hikes, they can’t bicycle, they can’t do a lot of the things that they love to do. So joint replacements are probably one of the most successful operations that orthopedic surgeons do and specifically knee replacements.

So getting back to the topic of partial versus totals with a partial replacement, the most common partial replacement, usually a unicompartmental medial or inside of your knee replacement. And that’s just because most people that develop arthritis in their knee usually wear out that inside compartment of their knee first. And so when we’re talking about replacing a portion of the knee, that’s usually what we’re talking about. But as I said earlier, you can replace the outside or the undersurface of the kneecap. Generally speaking,

And this is a big generalization as we work from inside to outside the knee, the inside or the uni-compartmental medial replacements usually fare better than the lateral compartmental replacements. I think generally, even in the skilled hands of an experienced joint replacement surgery surgeon, the success of the lateral or outside replacements just aren’t quite as good as the inside replacements. And then when we get up to the patella-femoral or the kneecap replacements, those certainly don’t fare as well as the inside or outside replacements. And so I think when you’re considering doing a partial replacement, you need to ask your surgeon those questions of what will I be able to do and what won’t be able to do with a partial and then also have a discussion about a total and what are the risks and benefits of partials risks and benefits of totals. So when you replace just one component of the knee, that’s essentially what you’re doing. You’re going in sometimes for a less invasive or smaller incision and you’re just simply replacing that worn out area.

And when you do that, not only are you replacing that worn out area, then you’re also then realigning the limb. And so that can certainly have profound impact on other joints such as our hip, our ankle or low back. I’m sure many of you that have had ankle, knee or hip pain will testify to the fact that it made other joints around that one particular area of injury a little more uncomfortable. And that’s something that we often see. So when you restore the alignment in that joint, it certainly can help other joints as well and decrease pain.

So when you replace a portion of the knee, the other question we get is, well, how long is that going to last? I think and this is a very gross generalization, but I think that you hope that you can get about 10 years out of a partial. Many studies out there will look at these and depending upon there’s something called the Oxford Knee, which is probably one of the most studied partials has a lot of data on that, but there are plenty of other brands or other partial knee replacements that certainly yield good success.

But if you can get 10 years, I think most orthopedic surgeons consider that a success. And so you can understand when we’re talking about doing partial replacements in patients that are younger. Well, most of my patients, we start talking about partials they go, well, if I’m 50 some years old, early 50s, I’d say fifty three and you’re telling me that I’m only going to get 10 years out of it, then that means that when I’m probably sixty three, I’m going to need to have a revision.

And then likely then if I get another 10 years out of another replacement then seven three. So you’re looking at having multiple revision surgeries in your lifetime and that is something to consider. So that’s something that I always talk about with my patients, and then whenever you do do a partial replacement, it does change the overall alignment, as we were discussing. And so that can make it more difficult for revision surgery in the future or if you had to have another type of surgery on your knee.

And so that is something that you and your surgeon need to discuss. But with a partial replacement, usually you do have a little bit less bleeding. There is a little bit faster recovery on the front end. But I think if you look at where patients with totals and partials end up at roughly six months, it’s pretty similar. So I think on the front end, you probably gained a little bit faster recovery. One of the things that has really come into popularity and I think will ultimately, in my opinion, change the way that we do joint replacements is robotic assisted uni-compartmental or partial joint replacement surgery.

And the reason for that is it’s just really critical that you get any implant in appropriate alignment, and everybody’s anatomy is a little bit different, and so what robotic partial replacements do is they allow us to take a CAT scan and build a 3-D model. I’m sure that many of you have heard about 3D printing. Well, 3D printing has made its way into joint replacement. And so we see that when we put the CAT scan into the computer, we build this model and we can on a computer screen before we’ve ever gotten to the operating room, determine what type of alignment we need to put that knee in.

We can make adjustments on the computer. So instead of actually having to make real cuts, we can actually plan that out on a computer screen before we get the operating room. And if we needed to make adjustments on the fly, so to speak, in the operating room, we can do that as well with the software. And so the data is early, but we are certainly seeing that with partials especially that the alignment is certainly more reliable. It’s improved.

And the big question when you talk about this with very experienced joint surgeons is, well, that’s great that the alignment seems to be overall improved. But you just told me that everybody’s alignments different and so how do we make those comparison? Well, I think ultimately it’s going to be the longevity. And so being that we’re early on, if we start seeing that these uni’s, these partial replacements are lasting well beyond 10 years, I think that that will be something that will be a game changer and make all surgeons really look at the use of robotics and uni-compartmental or partials as maybe a standard in the future.

We’re certainly not there yet, but I think that that is something that we’re going to continue to explore and something that we’re going to continue to look at. So I think that’s something that you can certainly discuss with your surgeons. There are patient specific guides with partial replacements. And so that’s where you will actually take a CAT scan of the knee and you will actually 3D printed model and then build patient specific guides. And those can actually help your surgeon as well.

So that’s another alternative to robotic assisted replacement surgery that can be done. And you can talk with your surgeon about that, essentially allowing your surgeon to use guides, cutting guides, that are built just for you and your alignment. And that can certainly make the operation faster. Often you can have less blood loss just because of, you know, less cutting and bone preservation. And so that can, in theory, make your future revision surgery better by having the alignment improved on the front end.

When you’re doing a partial, especially if you’re working with smaller incisions, sometimes visualization isn’t as good as it is with a total. And that’s a common question that we get is how big is my incision going to be? And often my response is as big as we need to make it in order to do a good job. And I think that’s what any surgeon or certainly experienced surgeons is going to tell his patients. We certainly don’t want to make a huge incision, but we’re going to make one is big enough in order to do a good job, because our goal is, of course, is to restore limb alignment and decrease pain.

So with a partial, you can return to just about all activities. But as I was saying earlier, we don’t want any of our patients to do impact. And that’s just because it can wear out the joint faster. It’s not to say that you couldn’t if you had to for a short distance run or jog, but it’s just going to wear out that joint. So we recommend against that. But you can certainly water ski, you can snow ski, you certainly can play doubles tennis.

I have patients to do that. Certainly can hike, walk, cycle. There’s a lot of things that you can do. But as we’re going to get into next, these are things that you can also do with a total knee replacement. And so many of you are probably asking then, well, why wouldn’t I just have a total why? What are the real advantages of doing a partial? Yes, it’s bone preserving. Yes, you’re only replacing one part of the knee, but I will tell you is being in practice for many years, I have seen patients that have had partials, who still have had persistent pain.

And that is the thing that is really frustrating, not only for the patient, but also for the surgeon. If you neglect to resurface or replace a worn out compartment, the worst thing that I have seen for patients is very frustrating is when someone comes back and they’re two or three months out and they say, well, the inside of my knee that you replaced feels great, doc, but, you know, still having pain when I go up and down stairs underneath my kneecap or pain on the outside.

And I’ve more than once have had patients that have had X-rays that have showed arthritis in the other joints. And maybe the surgeon has talked with the patient about doing a partial versus a total and maybe the patient selected to have a partial instead of a total and understanding that they may have to come back later for a total. But if you’re having to talk revision surgery within 90 days of having your uni, probably, in my opinion, should have had a total to begin with, which leads to the why not just have a total knee replacement done instead of a partial.

And I will admit that I do have bias towards that. Certainly I perform and can perform partials versus totals, and we certainly do cartilage replacements, which then sometimes can prevent people from having replacements altogether. But in my experience and in my hands and many of my colleagues, total joint replacement is the most reliable operation for knee replacement as far as decreasing pain and restoring limb alignment. And when you look at the longevity of totals versus partial, I think it’s fairly clear that totals can now the way that we’re putting them in, the plastics that we’re using, the inserts, everything that we’re doing now allows patients, I think, fairly realistically to be able to have a total knee last 20 years or more. Now, certainly factors that can shorten that up and a lot of that goes into the patient and their overall bone quality and certainly the experience of the surgeon. A lot of factors at play into that, some that we as surgeons can’t control and others that we can. I think that that’s certainly a discussion, though, with the patient. So when you talk about totals, that is certainly a very reliable operation, one that we’ve done successfully for many years. And that can be done with certainly the standard instruments or can also be done with patient specific guides where we build guides with CAT scans and 3D printing or as we talked about, with robots.

And I do think that as we get better at this, that we are going to do more robotic assisted joint replacement surgery and are several systems on the market and ones that are coming. So certainly something that you can discuss with your surgeon, if that’s an option or something that you want to consider. But total joint replacements in my hands and many of my colleagues is become a very reliable way to decrease patients pain and restore function. Again, as I was saying, one of the most frustrating things for any surgeon would be to do a operation in order to relieve pain and then have the patient come back months later and still have significant pain and have it be as a result of not resurfacing or replacing one of the compartments.

Even when you talk about joint replacements or total joint replacements, sometimes surgeons won’t even resurface the under surface of the kneecap. A lot of debate on that. I will tell you that in all my years of practice, I’ve always resurfaced the knee cap. I just don’t want that patient in my practice to come back and have persistent kneecap pain after knee replacement. And certainly there’s papers out there. And you can talk about the statistics of how many patients that undergo knee replacement surgery don’t have pain in the patella femoral or the knee cap joint after resurfacing it.

But as I always tell patients, even if it’s one out of a thousand, if you’re that one and that by resurfacing that kneecap, that that could have avoided one revision surgery and that could have avoided another operation for that patient, I think it’s worth it. And certainly for all of us as surgeons, it goes into your training and your experience. But in my hands, I certainly have found and I usually recommend that you replace the knee cap even when doing a so-called total

joint replacement. One may be thinking out there well, if you’re only replacing the inside and the outside how is that a total? Well, just has to do with the components because we’re completely replacing the femur. Whereas if you’re doing a partial or what we call a bi-condylar replacement, then kind of just the inside and the outsides. And so you’re kind of leaving that kneecap or the under portion of the kneecap. So I think that’s something that is important.

And when you’re contemplating joint replacement is to talk about all those things, because it is very frustrating, as mentioned, when you have to go back to the operating too soon afterwards. When you talk about activities with totals, as I mentioned earlier, I think you can actually do just as much with a total as you can with a partial. My patients are allowed to snow ski, they’re able to water ski and our area, we have a lot of older patients that like to play pickleball and that’s very popular.

And I let them play pickleball with their joint replacement. I’ll even have some patients that will play doubles tennis. I would certainly even have some people play basketball. Certainly we don’t let them try to run around a whole lot and kind of more of just shuffling around the court. But there are a lot of patients who simply just love to kind of just shoot around. And and I let them do that. And I think that’s certainly important for people to remain active afterwards.

And certainly cycling, which is a non impact activity, let people do that and swim. But the purpose of doing joint replacement is to give people back their knees. And I think that people wait too long to do replacements because of the fear that they’re going to have to give up activities. My experience has been that they actually regain function and that they actually take on activities that they were not able to do for years or even sometimes take on new activities.

And I think the most common thing that I hear from patients says, I wish I would have done that sooner. When we talk about the risk of joint replacement with any operation, we always talk about infections. And that is certainly real with joint replacement. But it’s extremely low when we are doing joint replacement certainly we do our best in order to limit the risk. If you’re diabetic or have elevated blood sugars, usually we’ll work with your internist or your family medicine doctor to try to get those blood sugars normalized as much as possible.

We look at something called a hemoglobin A1c, which is sort of an average of your blood sugars over the last three months and try to get that down to an acceptable level. And that number kind of is changed through the years, but certainly something that your surgeon and your family medicine or internist can discuss. But we do know that if you don’t have well controlled blood sugar that risk of infection goes up. We certainly give antibiotics before and usually a few doses afterwards.

We don’t usually extend antibiotics beyond the twenty four hour period or usually two doses after just for the fact that you can build a risk for resistant bacteria. And we certainly don’t want to contribute to that. And most joint replacements these days can be done almost in an outpatient setting for people that meet certain criteria, whether it’s a partial or total, there’s certainly people that can go home. I think with partials as mentioned earlier, more of those could potentially go home the same day with blocks in order to control pain or certainly with local medicine injected or oral medicines.

But one of the things that we will usually do and I do still is just keep people in the hospital just overnight so that if they do have increased pain, we can control that pain with IV medicines. But the move is going towards outpatient joint replacement. A lot of that is driven by the cost of hospitalizations. But I also will say I think that if you can be at home and have your pain controlled, I think that certainly better for patients, they’re going to be more active.

Certainly infection, I believe, actually goes down because unfortunately, even in the hospitals and everything that we do to decrease infection rates, we know that the longer that someone stays in the hospital, the chance of them picking up bacterial infections goes up. So when we can get patients out of the hospital, we’ll do that. And most of the time that’s in under twenty four hours, unless there’s medical reasons why someone needs to stay. So, with robotic surgery and robotic totals

as I was talking with partials, we will build a CAT scan. We’ll build a model in the computer based off of a CAT scan, and then we will certainly do the operation on the computer before we get to the operating room. And I do think that that helps with alignment. And because we don’t have to drill a hole down the center of the femur and big holes down the center of the tibia, so our thigh bone and our lower leg bone, that there’s less bleeding afterwards and so less pain one would expect, and that’s something that we’ve seen. And the complications with robotic surgery really, I think, are actually less in many cases in the hands of experienced surgeons than the traditional non patient specific guides.

A reason for that, again, with alignment and then there’s some safety factors that with the robot, the robot won’t let you cut outside of the plane. So it actually will shut off. So even if the surgeon wanted to and of course not surgeon, whatever, but if a surgeon wanted to even push outside of the plan, they can’t. So it’ll stop you and you’d have to rethink things. And so that’s a safety factor, sort of like on an airplane where you have warnings and lights that even if a pilot was certainly trying to push the nose of the plane down or trying to do something that put the plane at risk of stalling or not flying, that it would alert the pilots.

And that’s what robots do. It doesn’t take in the comparison of a pilot. It doesn’t take the pilot out of the cockpit and it doesn’t take the surgeon out of the operating room. The surgeon and the robot are still working together. And I really think that in the future, with artificial intelligence, augmented reality, where you’re going to see surgeons actually wearing goggles and there will actually help them visualize your anatomy and where all the important structures are, I think that we’re going to see more and more of that.

And for people that have done a lot of robotic surgery, one of the things that they will comment on is that it actually makes the replacement process consistent. Time and time again, experienced joint surgeons will say that their replacements, their post-operative x rays come out and look perfect to quote a few of them. And that it does take a few cases for the surgeon to get experience. But once they overcome that learning curve, that certainly the results are looking very, very promising.

So I think whether you do a partial or whether you do a total replacement, certainly between you and your surgeon, I’ll admit that I think the success of totals is better than partials. And the other thing to consider is that, generally speaking, when we do a joint replacement, on average, it’s going to last when we do a revision surgery about half as long as the other one. Now, I know that that’s a gross generalization, but a lot of my experienced colleagues and some of the literature will support that, that when each time you go back and have to do revision surgery, you’re having to do some more damage to the knee, take some more bone.

And so that certainly will make it so that the next operation may not last as long. It certainly could and there’s going to be outliers. But generally speaking, you don’t want to have to have an operation any sooner than what you absolutely need. And I think if we can do the first operation, that’s the best operation for that patient it’s going to last the longest. That’s what matters the most. And those are individual discussions for you and your surgeon.

But I think that a total replacement is certainly going to allow patients to do the same things as a partial and be more predictable, more reliable pain relief, more reliable limb alignment, or restoring the normal alignment of a limb. And I think that that’s important. It’s also going to make any revision surgery in the future a little bit easier, especially if you’re using robotics or even the patient specific guides, in my opinion, that you’re able to take less bone.

Now, certainly you could plan for with any of these things, robotics or the patient specific guides to take more bone. But I think that it allows you the ability to take less bone so that then in the future that you will have more bone to work with if a revision or repeating a joint replacement surgery would be necessary in the future. So I think those are all things to consider. I think as far as scar tissue, manipulations, those are things that sometimes if patients aren’t able to restore their motion, I think with any type of joint replacement, that’s something that we are concerned about.

I think getting up and being active right away with your surgery is important whether you have a partial or total. I recommend that patients will go to outpatient therapy as soon as possible. Some patients will have a few days of home health where therapists and nurses may come and visit. Sometimes that’s convenient, especially depending on patients overall health status. But most of the time that’s something that can be due at home. Rarely these days does somebody have to go to rehab where you go and stay somewhere for a few weeks.

That used to be more common many years ago. Most of the time now with our techniques, we can actually get patients home within twenty four hours and will often recommend home health for a few days and then outpatient therapy. I think getting to outpatient therapy critical in order to decrease scar tissue. One of the other things that we use in our practice, I know this is controversial, is CPMs or motion machines. There’s a lot of studies out there now that say that they don’t change the outcome, although I think most of us would agree that in the first few weeks or first few months that the motion is improved.

And I really think that it is beneficial and in my experience certainly has decreased the need for manipulations. I certainly have only had to do a handful of manipulations in my career. I think that by using the CPM or continuous passive motion machine, that’s something that’s helpful. In my opinion, I just think that insurance companies are trying to pay for less and less. They’re trying to justify not paying for certain things. I will tell you that patients in my practice will usually just pay a rental fee for these devices.

And we have found them to be really helpful so the patient can start moving right away. I think if you just go home and you just are only having a therapist come out once a day and maybe moving you actively for 30 minutes or so, that is certainly going to take you a little bit of time to catch up. And at least initially, in my experience, instead of if you had a PM or one of those motion machine devices. So ask your surgeon about that.

I know that a lot of surgeons have strong opinions about that, but in my practice, I’ve certainly found that to be helpful. I don’t know of why you wouldn’t or couldn’t use one. I certainly don’t know what harm it would cause. And so if it’s not going to be harmful, then why not use it if it is a potential benefit? Because I think especially now as we’re doing joint replacement on younger, younger patients, people want to be up and about.

So even if it did have benefit in the first few months, then I think that’s value. And if you want to argue that in six months, those that use those motion machines versus those that didn’t the ends up the same. Well, that may be the truth, but I think if you can get someone up and active and restore that motion early, I think that that’s psychologically beneficial and I think certainly functionally beneficial for people to be able to return to their more active lifestyle.

So that’s my opinion. I think that that’s something that you can talk with your surgeon about. A lot of times your surgeon will also use ice machines. We have found that to be helpful. You can use ice packs, but usually we use circulating cool water, sometimes referred to ice machines right afterwards, and that helps with swelling and pain. And that’s something that you can talk with your surgeon about. I think that’s something that’s very helpful. Again, insurance companies sometimes aren’t paying for these things anymore, but I think that that does add value.

And you can talk with your surgeon about that. And I think that once you have your replacement, getting up and being active is the most important thing. If you’re contemplating having a joint replacement, ask where your surgeon operates. Oftentimes the hospitals or surgery centers and yes, we’re doing operations at surgery centers these days for the right patient. Not everybody is a candidate for that. But as I said, if you can get somebody in and home within twenty four hours, I think that that’s probably best for them.

Certainly decrease the risk of infection, in my opinion, and help them to be at home where they’re going to be more comfortable usually. So that is something to consider. But often the facility will have what we call a joint camp or even preoperative education, where you can go in and you can work with the physical therapists, you can learn how to use a walker or crutches. Those are devices that we may recommend after surgery just to help you to get around.

My experience has been people will use a walker or a cane for maybe a week or two. And when it comes to driving, if they’re not having to operate a clutch and are just using an automatic transmission, usually within a couple of weeks, my patients on average are able to drive independently. So those are certainly things to consider. If you don’t have friends or family around arranging to have help for sometimes a few weeks or nowadays we’ve got these ride sharing apps, you certainly can use those for a few weeks to kind of get you to and from appointments or even initial therapy visits.

That’s certainly something that we didn’t have a few years ago. So, things to consider and the planning process. But it is certainly your decision and one that should be made with your surgeon about partials or totals. I think that you probably have heard that I do lean towards doing total joint replacement, just because I think it’s more reliable, I think, and the literature shows that totals are going to last longer than partials. I think that once you’ve done a partial, you sort of burned a little bit of the bridge and it’s difficult to go back and undo.

And if somebody doesn’t necessarily do a lot of partials, the chances of them taking too much bone is certainly a risk. And then it makes it more likely that when you go to have a revision surgery in the future, that that may make it more challenging for your surgeon. But joint replacement, one of the most successful things that we do. If you’ve gone through all the conservative options, injections and therapy and bracing and you’re still suffering and you’re still having pain, then I would encourage you to find an orthopedic surgeon thats experienced in joint replacement close to you and and talk with them and discuss the different options.

As we’ve talked about today, there are lots of things that are out there. The technology is improving all the time, especially in the field of robotics. I think that’s something that you’re certainly going to see more of in the future and then coming in the next few years, augmented reality, where you’re going to see surgeons wearing certain glasses and goggles. A few years ago, you heard about Google Glass. I think you’re going to see more and more companies coming out with things like that to help the surgeon to do an even better job.

So I hope that that answers some of your questions. I thought that this would be an interesting topic since I get asked every day about this. But ultimately, this is something that you want to talk about with your surgeon. And certainly friends and family will have opinions about that. But I really think it’s important to just discuss that with your surgeon and sometimes maybe even talking with a few surgeons and just finding out how many joint replacements a surgeon does per year.

I think even as you contemplate where you’re going to have your joint replacement, that’s something else to consider that places that do more joint replacement certainly going to have more of the resources and help with recovery, all those things. Joint replacement is a team approach. Certainly in our practice we have from our front office all the way to the surgeons and the hospitals and the nurses and the therapists, everybody is part of the team. And the goal is to help our patients and should be to help you to regain function, to have less pain and to get your life back.

So thanks for tuning in. I really do hope that this was helpful. Let us know if you have any other ideas of topics that you’d like to hear about. Respond. Let us know. Thanks for tuning Into the Call Room. This is Dr. Berry signing out.

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